David Pantalone : Stimulant Reduction Interventions for Sexual Minority Men

guymHIV Endgame 3

David Pantalone, Director of Clinical Psychology, University of Massachusetts, Boston

Men and Meth

A growing number of gay men are using crystal meth for sex. What’s the impact on their health and lives? What are the challenges of dealing with a meth addiction? What about treatments?

Descriptive Transcript

So I’m gonna talk about stimulant reduction interventions for sexual minority men. I use sexual minority men to include gay men. By men, men who identify as heterosexual but have sex with other men or any other non heterosexual sexual orientation. So I used that intentionally. I am a faculty member at UMass Boston and director of the clinical psych doctoral program there, and a colleague of Colonel Cleary who presented earlier at the Fenway Institute of Fenway Health. So the research arm of Fenway Health, which is the largest LGBT focused Health Center east of the Mississippi in the US. All right so those are my disclosures. Just some NIH funding. So what you’ve been what we’ve been talking about for the past 40 minutes is about how much meth impacts the sexual minority male community and the ways in which it gets embroiled in sex.

So we know that meth use is much more common among sexual minority men than non sexual minority men. 20 times more common and we know that it’s associated with some health behaviors that we like to focus on, including condomless for HIV negative men, also for HIV positive men, and there’s so much data on this that no matter how you measure it. So if you measure it at the event level, at the day level, you find it if you measure it in aggregate you still find it, and it’s also associated with antiretroviral medication non-adherence. So really important. So Connell and our colleagues, Matthew Mamiaga, Steve Safran we work together and apart on interventions that combine trying to change some health behavior and trying to reduce some mental health symptom. So mostly we’re working on HIV related health behaviors, and so we’ve been making these combination interventions, that try and dually do those things.

So as an intervention developer I like to start with the question that’s like, well what should the intervention even have in it? How do we know what it should look like? Of course we need to know what the target population is, we need to know the symptoms right of the disorder. What are the thoughts, behaviors, emotions? What biological processes? I’m a psychologist not a psychiatrist so I tend to intervene at the behavioral level rather than the biological. The severity question is important too. Right. Does it need to be individual? Which of course is more resource intensive. Could it be group? Can it be out-patient? Does it need to be in-patient? Is medically supervised detox needed? Can it be a peer led? Does it have to be led by a professional? So these are important questions that go into the formative work. That we do try and figure out how to target. And then of course the cultural tailoring piece.

If there’s any contribution that the Public Health response to HIV has given to the public health literature more generally is, it isn’t true that one intervention works for lots and lots of people. Right, the cultural tailoring part is needed we need some level of cultural competence with whatever the identity group or population that we’re working with. So there’s more we need to know when we get in the room with a client. Also, which is why are they using the drug? Right, so not just that they’re using, not just does the person meet criteria for some esoteric disorder or something. Right, but but literally like what’s going on in that moment when you’re about to take it? What’s happening there? And we know a lot about in general the substance use motivations literature. It’s very well developed for alcohol and for marijuana use and it falls into these categories: coping, social enhancement, peer pressure, that’s for alcohol and marijuana. The marijuana use literature adds this openness to new experiences. That part seems important too.

There’s a one measure that that we tend to use in this area. We’ve been working on this sexual motives subscale we published in 2015, because we just heard from so many of our participants that our research participants that that was important too. So motives like wanting to be able to be more brazen to approach a sex partner or being willing to do more sort of adventurous sex acts. So yeah we know those are important, but we also really need to drill down and say okay, but in this population what what are their motives? Again not these big categories but like literally what’s going on? Right, so many sexual motivations there’s a literature from the aughts that’s really excellent, that starts off as lots of qualitative interviews and focus groups that helps us to know, if we’re providers trying to help a client or a participant reduce their meth use this is what we’re up against. Unfortunately. Right.

So some of the things that the David and Mark have been talking about, increased libido, increased time to orgasm, decrease in inhibitions, higher threshold for pain, reduced sexual anxiety, reduced fear of rejection, increased openness of sexual activity, some of that I said and then this habituation to the extreme dopamine rush of chem sex. So this is important of course, from a physical health perspective. But also there are other motives. Right. The psychological, behavioral, and social motives. So this when you talk to men who’ve been using using meth so much they talk about these other parts too. That for some of them and I think this echoes what what the guys were talking about, that it can start off as being about sex but the trajectory for many men it ends in sort of isolation. But this increased self-esteem, confidence, that meth is often but not always, or at least begins as a substance that’s used in social settings although again that may become more individual over time, and the sense of belonging that, and I appreciate that idea of thinking about connectedness and and loneliness and isolation.

And that part’s so important, and there’s so many factors that go into that for sexual minority men given the minority stress and the increases in energy and mood, and the weight loss that comes with it. And there’s increasing evidence about meth use continuing to be popular among the HIV positive, especially men over 50 who report in quote these qualitative interviews. It’s like I’m 25 again. Right. In terms of the energy and so it’s totally understandable. Right. When you think, okay this is what they’re getting out of it, it’s totally understandable that they would want to keep doing it, it just seems very reasonable to me. And just to say that it’s important to approach these from a mental health promotion perspective, that so much of the work that we do, and that I’ll talk about, has this sort of meth reduction tied into changing HIV-related health behaviors but that’s partly as it Connell said earlier that’s partly where, that’s where the money is, and so when we have participants come and join our research studies, I’d say more than half the time they may or may not be interested in changing some HIV-related health behavior but what they’re really often saying is I really want help reducing my meth use and there doesn’t seem to be another place around that that’s willing to help me with that.

So we also really talk about, and sort of frame the conversations with the participant, says what were the reasons that a person started using meth and then of course the reasons for continuing and those are often different reasons. It’s a useful therapeutic conversation to see how that changes over time. So the question is what interventions are out there? There are some. There’s a good systematic review from from 2012 so it’s a little bit dated at this point but there’s another one that’ll talk about in a minute, but in brief they’re just aren’t enough, not enough interventions for us to really talk about, okay this is what works. I’ll give you some hints about things that work some of the trials have been repeated so that’s better evidence. Most of then tend to work somewhat but like many behavioral interventions that are too short that the effects tend to dissipate over time unfortunately. I kind of also made this point earlier that’s like when you when you kind of sit disciplinarily, I sort of sit where Public Health meets Clinical Psychology, and my Public Health colleagues are often saying like can we do that in two sessions, and my clinical psychologist colleagues are saying how about sixty sessions, and very often the funders make the call, and so it ends up being ten or fifteen sessions that we see clinically, but that it tends not to be enough, there’s a lot more we could do with some more sessions at the end.

But resources are what they are. So there’s this really excellent review. It’s not a systematic review but close. Hill 2015, that talks about evidence-based practices for the treatment of meth dependence. So I’m gonna just give some highlights from that document to see what practices have some empirical support. So taking a harm reduction approach seems to be really helpful, and David and Mark were talking about this before, that this idea that you know when participants come in I start working with them, they often don’t want to stop using meth for all of the reasons that we just talked about that are totally understandable, but usually their goal is to sorta like turn down the volume on the meth use but the but the problem is that’s really hard, obviously. Right. So if a participant says to me I’m using every weekend so four binges in a month and I want to go down to one bing a month this is a laudable goal of course. I say okay great, how do you want to do that? They say whatever. We make a plan and then do you want next weekend to be one that you don’t use? Yes, okay.

So I see them the next week and they used. So I say okay what happened? So that the goal of reducing use, the strategies that a person needs to use to reduce use. Like what is reducing use? Reducing use means a person has an urge or craving and then they use some skill to not use. Well guess what? That’s the same process that a person goes through to stop using altogether. Right, you just do it longer, you do it more times maybe you need more skills and more strategies that work in more and more settings. Maybe the ones that a person used don’t work any more and so you have to be creative and get some new ones. So often clients for me start with a harm reduction goal. Let me use less but they often like really like 80 percent of the time maybe. Eventually say you know what actually might be better, of course I push them in this direction, you know what might be better? How about a period of abstinence? Like how about abstinence for 30 days or 60 days or 90 days or six months? Whatever. Always comes from them. I’m supporting them. I’m not setting goals for client. And then we say okay but and after you have this period of non-use what if you, in that moment, made a decision about whether you want to keep going with non-use or go back to using?

But for me clinically that’s where it’s at. Right. Because that person, that future person who didn’t use say for three months, they’re in a totally different headspace. They have three months of non-use life. Right, but they’re in a different spot in terms of being able to make a decision about what happens next. So the data, and the data bears this out that this idea that it’s useful for a therapist to be flexible about harm reduction or abstinence goals over the course of treatment. Taking the motivational interviewing approach. This is what I was talking about a minute ago. This idea that motivational interviewing and evidence-based intervention, lots of long history and substance use, alcohol use, reduction very helpful, really helpful for clinicians to work with clients who are ambivalent about change. Right. Maybe today I want to reduce my use but maybe tomorrow I won’t. As a therapist that can feel so frustrating. That’s like, no but before you said you wanted to reduce. I want that version of you again. Right, but we get what we get and so the the useful part of motivational interviewing, I think, one of the most useful parts is this idea that it prescribes intervention.

So it tells the therapist what to do based on whatever the client’s presentation is in that moment, and doesn’t penalize the client for not wanting to change today. So from the therapists perspective it’s like oh today you want to keep doing what you’re doing. Okay. So we’re just gonna highlight discrepancy and move on from there. Right. And continue to build our relationship. So that if the client does change his mind and decide later he wants he wants to make a change. Great. I’m here. Contingency management is a different kind of intervention. I put it in brackets because it sort of stands alone, but it’s this idea of using tokens or money for negative urine screens. And so some people say it’s our bribery. It comes from learning theory. Has good data and in terms of while a person’s enrolled in a contingency management program you see a huge reduction in in drug use. I mean we’re talking about the meth use literature but it’s true for lots of literature, but it doesn’t stay over time. We can take more questions about that later if folks are interested. But there is a really excellent intervention it used to be called the matrix model it’s been sort of rebranded as it became more culturally tailored for sexual minority men.

Called getting off, a 16 week program, forty-eight sessions, quite well defined, each of the sessions. It combines individual and group therapy. Focuses on the client. Focuses on their social network. For all of you who brush up against substance use in terms of treatment or experiences. It’s like the social network is really key. We’re treating the individual or thinking of the individual. But it doesn’t happen in a vacuum. So this is a great intervention. Obviously 48 sessions over 16 weeks is extremely resource intensive so that we can understand in a way why it hasn’t diffused more. But it is out there and has excellent data, and there’s also just more generally support for cognitive behavioral therapy techniques. That’s part of the getting off intervention and that’s part of the work that we’ve been doing at Fenway also. So being really concrete to the extent that it’s possible about identifying internal triggers and external triggers. Modifying thoughts if needed but teaching skills. But just in general having this problem solving approach that’s like oh you know. Every time the client comes in and says well I had a slip I used. So just to say okay, well what’s the lesson? Let’s figure out what we learned from this experience and then we’ll take that knowledge with us to the next situation. So this brings us to the intervention that I was asked to talk about.

Which is Project Impact. Which is at Fenway Health. We have a lovely building, you should come visit us. Matthew and Steve. Hi guys. They’re my colleagues in this work the principal investigators of this study. Sort of focused more on the clinical aspects. So to make this intervention, picture it in 2007, the meth epidemic in the US. The West Coast was starting to die down, the East Coast was still going strong, but moving in the direction of less use. So we did this formative work twenty interviews with sexual minority men who reported using meth in the context of engaging in unprotected sex. And actually in this study the men had recently sero converted through those sexual experiences. And so we were asking them well what do we need to know about your experiences as we go about trying to design an intervention? What they told us was almost all of them mentioned this loss of interest in previously enjoyed activities. So to mental health folks in the room that sounds like depression. Right. One of the nine criteria for depression is anhedonia which is literally defined as loss of interest in previously enjoyed activities. So we were like oh maybe we need to be thinking about bringing some elements of depression treatment into the substance use and sexual risk reduction realm.

So participants, just simple quotes about “awful depressed mood”, “loss of interest in everything”, “having that feeling I’m a failure”, more of those thoughts, “losing interest in everything”. So we thought oh. Well there’s a there’s an intervention for that. So we made that we did a pilot study. An uncontrolled pilot study of about twenty guys, and then a mini randomized trial of about fifty guys. And so I’m gonna tell you about that a little bit. But basically the thing we did was go to the depression literature and say what’s the best treatment for depression, that seems like it’s possible that some part of it would work in our context. And so we went to cognitive behavioral therapy for depression. CBT for depression has two parts. One part is the cognitive parts. One part is the behavioral parts. That’s not surprising. Right. Look the cognitive parts, cognitive interventions, they’re just harder to learn. They’re harder to do.

I’m a behavioral person, obviously as I’m talking smack about about cognitive folks. But love you. Thanks for doing that work. It’s so hard to train people in it to do it really well. And bad cognitive therapy basically says to the client you know the core of your problem is because you’re thinking wrong. Well that’s not invalidating. But what the evidence says is that if you look at, if you separate out the cognitive parts and the behavioral parts and you just treat people with one part. Right. The group that gets the behavioral strategies for depression reduction, they do the same. They do just as well and it’s so much easier it’s so much easier to train new therapists in. And so that’s the direction we went. So we combined. We made Project Impact this intervention where we combine behavioral activation which is getting people reengaged with non substance use activities that are likely to elicit the feelings of mastery or pleasure. That’s the core of a BA for depression. And so that’s what we did for us too we had two sessions of standard risk reduction counseling and then the behavioral activation, a session of relapse prevention. What happened it was amazing. It worked really well.

Worked really well you can see from baseline to post those beautiful lines and then those gains were maintained over time. Just really great. So then we did another study. The second study though, it was a different moment in the sort of meth use chronology in Boston. Which is that in the first study folks met criteria for abuse meaning a sort of lower level problem but in the second study everyone met for dependence so this much more intense problem. And so when we made our second intervention we had to add in some cognitive behavioral therapy for substance use components. And so it sort of looks like this. So the risk reduction sessions, then we added in the CBT for substance use, then the behavioral activation, then the relapse prevention. Of course always with trying to generalize whatever we do in session into the person’s life outside. So with homework they love that. And really tracking at the beginning of every session where are you at on your substance use? Where you add on your mood? Where are you at on on your risk behavior?

So that’s consistent focus on whatever issues were most salient for the guys over the week. What happened? That one worked really well too, so good news for us. Reducing unprotected, sex reducing the sex and meth, and resulting in longer continuous periods of abstinence. This is embargoed, so I’m not showing you the numbers. But the secret is it was fifty days was the average length of non meth use for our intervention group, compared to twenty days for the control group. So it’s really different. So we’ve been working on a… We now have a fully powered study. So 240. We’re recruiting 240 guys. Half in Miami, and half in Boston. So that’s what’s going on with us. Thank you. [Applause]